Excessive Imaging in Early-Stage Breast Cancer Detailed in Study

Norah Lynn Henry, MD

A study involving nearly 30,000 patients diagnosed with early-stage breast cancer has found that up to 60% of these women received imaging tests such as CT, bone, and PET scans that were not medically justified, contrary to national guidelines.

The findings were released in advance of the American Society of Clinical Oncology (ASCO) Quality Care Symposium, which was held February 26-27, 2016, in Phoenix.

“The chance of finding cancer that has spread to other parts of the body on a scan is only about 1% for a woman with stage I or stage II breast cancer,” said lead study author Norah Lynn Henry, MD, an associate professor of internal medicine at the University of Michigan, in a statement. “It’s concerning that so many women are receiving tests that have little benefit to them but may lead to excessive radiation exposure, invasive procedures, anxiety, and financial hardship.”

Advanced imaging has been decreasing over time for women with stage 0, I, and IIA breast cancer, especially since the launch of the American Board of Internal Medicine Choosing Wisely campaign, ASCO noted in a statement. However, this study indicates that the rate of such testing for patients with stage IIB disease has remained high. The study involved 29,170 women with stage 0-IIB breast cancer receiving care at 1 of 25 hospitals participating in the Michigan Breast Oncology Quality Initiative. Twenty percent (n = 5954) had at least one imaging test performed within 90 days of diagnosis. Average testing rates varied by stage, with the highest rates (53%) occurring in women with stage IIB tumors.

Women who were black or who had HR-negative, HER2-positive, or higher-grade cancer were more likely to undergo advanced imaging. There was significant variability in testing rates among the different practices, with more than two-thirds of women with stage II disease undergoing scans at some hospitals.

“The scans we have today are very sensitive, meaning they pick up many small abnormalities, most of which are never going to be clinically important,” said Henry. “However, if we find small lung or liver nodules, we often have to keep repeating the scan to make sure those nodules don’t change. At each step of the way, you are increasing anxiety for the patient—while they are waiting for the scan to be performed, waiting for results, it snowballs.” These study findings align with earlier research in other regions of the country, and the next step for the researchers is to analyze the reasons underpinning the unnecessary testing more closely with an eye toward developing decision tools for practitioners and education for patients.

“For women newly diagnosed with early-stage breast cancer, advanced imaging is generally not medically necessary, and we know it has potential to lead to harmful side effects,” said Merry-Jennifer Markham, MD, ASCO spokesperson. “It’s troubling that imaging scans are being ordered for many women with stage 0-IIB breast cancer, and this study points to the need for further research as to why this might be occurring so frequently.”

Henry NL, Bruan T, Lusk E, et al. Variation in use of advanced imaging at the time of breast cancer diagnosis in a statewide registry. Presented at: ASCO Quality Care Symposium; February 26-27, 2016; Phoenix, AZ. Abstract 287.